fixed functional appliances

fixed functional appliances types and its description.
it includes all the varieties of appliances and its modifications , advantages and disadvantages, along with the skeletal and dental effects that are obtained by the appliances. varieties of herbst appliances.....etc

1. GOOD MORNING

2. FIXED FUNCTIONAL APPLIANCES Presented by : Dr Harish kumar , PG II year, Dept of orthodontics, MIDS, Nizambad .

3. contents Introduction Definition History Indications Mode of action Classification Based on mode of action Classification by RITTO KORRODI (2001) Based on type of force produced Rigid FFA Flexible FFA Hybrid FFA Conclusion

4. INTRODUCTION

5. DEFINITION an appliance that produces all or part of its effect by altering the position of the mandible Functional orthopedic treatment seeks to correct malocclusions and harmonize the shape of the dental arch and orofacial function. Developed primarily in Europe by many clinicians in an affort to stimulate mandibular growth , and aid in the correction of skeletal class-2 malocclusion s It is intended to alter mandibular growth . DEFINITION

6. Disadvantages of removable functional appliances Very bulky, Have unbalanced fixation, Absence of tactile sensibility, comfort, Apply pressure on the mucosa (causing gingivitis), Cause problems in deglutition, speech Reduce space for the tongue & commonly affect facial appearance.

7. Unfortunately due to the bulk and inconvenience , removable functional appliance fails to attract the patient’s cooperation. In addition, their intermittent wear does not elicit continuous muscle activity , a factor that is very essential for promoting skeletal change. Patient cooperation - an important factor, failure to adhere to prescribed schedules of removable appliance wear will result in slow treatment response or no response at all. To reduce these factors the Fixed functional appliances were developed

8. HISTORY : NORMAN KINGSLEY - Bite plate Bite plate for jumping the bite. 1 st to use the forward positioning of the mandible in orthodontic therapy. T he bite plate was the forerunner of the modern functional appliances. HISTORY

9. Whereas Fixed functional appliances first appeared in 1910 when Emil Herbst presented his system at the Berlin international dental congress. Since then and up to the seventies, very little was published on this appliance. It was at that time that Hans Pancherz brought the subject back into the discussion with the publication of several articles on the Herbst in 1979.

10. “ NON-COMPLIANCE CLASS II CORRECTORS” Fixed functional appliances are commonly called as

11. They are used full day, which implies continuous muscle activity for mandibular growth. They are smaller in size allowing better adaptation to perform such functions like swallowing, mastication, speech and inhalation. allow greater control as they are fixed on both the arches. REMOVABLE FUNCTIONAL APPLIANCE FIXED FUNCTIONAL APPLIANCE

12. HISTORY : Functional appliance Increased contractile activity of lateral pterygoid muscle ++ of RDP / Bilaminar zone Increased growth stimulating fctors Enhancement of local mediators Reduction of local regulators (factors having – ve feedback effects on cell multiplication rate) Change in condylar trabecular orientation Additional growth of condylar cartilage Additional subperiosteal ossification of post. Border of mandible Legnthening of mandible MODE OF ACTION

13. MODE OF ACTION

14. The correction of skeletal anomaly in young developing individuals . a) In skeletal class II cases with retrognathic mandible. b) In skeletal class III cases with retrognathic maxilla . Making use of the residual growth left in neglected post-adolescent patients who have passed the maximal pubertal growth and are too old for removable functional appliances . . INDICATIONS In adults patients Used in upper molars distallization to correct dental class II molar relationship. Used to enhance anchorage. Used as mandibular anterior repositioning splint in patients having Temporo-mandibular joint disorders Post-surgical stabilization of class II / class III malocclusion. Fu nctional midline shifts can be corrected by using the appliance unilaterally.

15. CLASSIFICATION

16. Rigid FFA Hybrid FFA Flexible FFA Herbst its modifications MARA MPA (I, II, III, IV) MARS IST Biopedic appliance Ritto app Magnetic Telescopeic Device UBJ Hjasper jumper Adustable bite corrector Churro jumper Amoric torsion coils Scandee tubular jumper Klapper super spring Bite fixer ( ormco ) Flex developer Eureka spring Forsus Twin force bite corrector Calibrated force module Alpern class II closer Classification by Ritto korrodi (2001)

17. Intermaxillary non compliance appliances Intramaxillary non compliance appliances Herbst , its modifications Jasper jumper Eureka spring Adjustable bite corrector Forsus MPA (I, II, III, IV) Biopedic app MARA Calibrated force module Pendulum app. Distal jet Repelling magnets Jones jig Based on mode of action and type of anchorage

18. PUSHING FORCE PULLING FORCE Herbst , its modifications Jasper jumper Eureka spring Adjustable bite corrector Forsus MPA (I, II, III, IV) MARA SAIF Appliance (Severable Adjustable intermaxillary Force Spring ) Based on type of force produced Jasper jumper Adustable bite corrector Churro jumper Amoric torsion coils Klapper super spring Bite fixer ( ormco ) Flex developer

19. RIGID FIXED FUNCTIONAL APPLIANCES

20. Developed by Emil Herbst (1872 – 1940) in 1900s. He called his appliance “ Okklusionsscharnier ” or “ Retentionsscharnier ” ( Sharnier = Joint) and Retention was added since the upper part of the appliance served as a retainer for an expanded maxillary dental arch . Herbst presented his appliance for the first time at the 5th international Dental Congress in Berlin in 1909. It was rediscovered by Pancherz in the late 1970s Herbst Appliance ( EMIL HERBST ) – 1910

21. The Herbst appliance is basically a fixed bite jumping device for the treatment of skeletal Class II malocclusions. A bilateral telescope mechanism keeps the mandible in an anterior-forced position during all mandibular functions such as speech, chewing, biting, and swallowing. The telescope mechanism (tube and plunger) is attached to "orthodontic bands, crowns, or splints.

22. The tube is positioned in the maxillary first molar region and the plunger in the mandibular first premolar region. The telescopes allow mandibular opening and closing movements and when constructed properly lateral jaw movements are also possible

23. Each telescope consists of a tube, a plunger, 2 pivots (axle), and two locking screws that prevent the telescoping parts from slipping past the pivots. Length of the plunger should be kept at a maximum to prevent it from disengaging from the tube. A large interpivot distance prevents the plunger from slipping out of the tube when the mouth is opened wide.

24. ORIGINAL HERBST DESIGN : Had the telescope mechanism placed upside down (with plunger attached to the maxillary molar crown and the tube on the mandibular canine crown). Tube had no open end , thus not allowing the plunger to extend behind the tube.

25. The telescoping parts of the Herbst appliance were curved conforming to Curve of spee and were made of German Silver or gold( worn more than 6 months)

26. TIMING OF TREATMENT : Pancherz , Hagg, (1985)  Most favorable time - peak of pubertal growth spurt . Pancherz & Hagg (1988)  Indicated that the patients treated at the initial closure of the middle phalanx of the third finger (MP3FG) had the greatest amount of condylar growth Ruf , Pancherz (March 2003)  permanent dentition or just after the pubertal peak of growth corresponding to the skeletal maturity stages FG to H of the middle phalanx (implying the precapping to preunion stages of epiphysis and diaphysis )

27. Perfect end result cannot be obtained exclusively with Herbst. Class II cases cannot be treated to a perfect end result with the Herbst appliance exclusively. Many cases will require a subsequent dental-alignment treatment phase with a multibracket appliance .

28. class II div 1 The sagittal jaw base relationship is normalized and the Class II malocclusion is transferred to a Class I malocclusion by means of the Herbst appliance Tooth irregularities and arch discrepancy problems are treated with a multibracket appliance (with or without extractions of teeth). 

29. class II div 1 Alignment of the anterior maxillary teeth Transformation of the Class II malocclusion into a Class I malocclusion Tooth irregularities and arch-discrepancy problems

30. Herbst appliance indications: Most suitable in the treatment of Class II malocclusions with a retrognathic mandible and retroclined lower incisors In young patients, so that growth might be influenced effectively. Maxillary and mandibular teeth should be well aligned and the dental arches should fit each other in normal sagittal position

31. Skeletal changes The increase in mandibular length - due to condylar growth stimulation as an adaptive reaction to the forward positioning of the mandible the gonion angle increased slightly. (This may be due to a more sagittally directed growth of the condyle or it may result from resorptive bone changes in the gonion region, probably as a consequence of an altered muscle function during bite jumping). Stimulating effect on mandibular growth + restraining effect on maxillary growth

32. Dental changes When jumping the bite, occlusal contacts existed only between the incisors while the buccal segments were out of occlusion. Thus, vertical tooth eruption and growth in the posterior segments were allowed to take place freely. This accounted for the reduction of overbite and the increase in lower facial height found in the patients

33. Herbst vs Activator Functional therapy with activators is often used to influence mandibular growth. However, it has not yet been shown that treatment has any significant effect on condylar growth. This can be explained by the fact that the activator is used only 10 to 12 hours a day. Because of this, the threshold for adaptive remodeling processes in the condyle will not be attained. When the Herbst appliance is used, on the other hand, the mandible is continuously held in an anterior jumped position 24 hours a day

34. Treatment results using herbst appliance : Normal occlusal conditions occurred in all patients. Maxillary growth may have been inhibited or redirected. The SNA angle was reduced slightly. Mandibular growth was greater than average. The SNB angle increased. Mandibular length increased, probably because of condylar growth stimulation. Lower facial height increased. The mandibular plane angle, however, remained unchanged. The convexity of the soft- and hard-tissue profile was somewhat reduced.

35. Herbst problems Mandibular incisor fracture. Rapid intrusion of mand. PM1 Repeated breakage and loosening of PM1 bands occurs . Limited to pts wth erupted PM1 and not for early corrections in children. As it attached to lower PM1 and M Depression of lingual bar Gingival impingement ulceration Shortens plungers sleeve combination Deactivates appliance To compensate – replacing upper sleeve

36. Herbst modifications (1982) Herbst staineless steel crowns (1982) Bonded herbst appliance (1984) Acrylic splint herbst (1989) Edgewise bioprogressive herbst (1994) Fixed removable herbst appliance (1996) Flip lock herbst appliance

37. Herbst staineless steel crowns ( LANGFORD ) - 1982

38. Bonded Herbst appliance ( RAYMOND ) - 1982 Advantages Instead of PM1 band – entire mand. Dentition, thereforpts at any stage of dental development can be fitted with herbst Intrusion of lower premolar avoided as whole dentition is used as segment Prevents mesial migration of incisors Tissue impingement avoided as there is no lingual wire Failure due to breakage of band is eliminated

39. Edgewise Bioprogressive Herbst appliance ( TERRY G. DISCHINGER ) 1989 It allows orthodontic tooth movement during orthopaedic correction It permits a smooth transition from herbst treatment into fixed finishing appliances Goal : to place edgewise wire as quickly as possibly to maintain torque of max incisors while class 2 is being corrected

40. 36, 46 banded Upper full arch bonding, Lower only incisors bracketed 0.040 lingual wire joins the mand. Crowns and bands No transpalatal arch in maxilla - to facilitate rotation of maxillary crowns during class 2 to class 1 shift Double buccal tube on max. molar crown serve as arch wire slot, extra tube is used to hold archwire that intrudes max. incisors Aw is tied back to hook on each upper molar tube to prevent space opening b/w pm2 and m1 Mandible - .022 x .028 slot on each ss crown accommodates aw Bioprogressive Sectional mechanics used in LA until utility arch can be placed through incisors into slots on ss crowns

41. Advantages Orthopaedic + Orthodontic at sametime Proper maxillary incisor torque and arch alignment achieved Mandibular arch is leveled and overbite is corrected Dumping of LI cuz of herbst app is avoided by using a lower utility arch Stability enhanced – by levelling lower arch, and thus eliminating any anterior tooth contact upon removal of app. Disadvantages Fitting - placing – removing Relatively costly cuz of skill required to construct it

42. Ss crowns = Instead of 16, 26  55, 65 Instead of 34, 44 / 33, 43  74, 84 If any teeth exfoliates – pause the treatment until permanent teeth erupts to attach ss crown on it Treatment competes within 12- 18 months As skeletal problem and abnormal muscle function is modified, Lower crowding is spontaneously corrected and remain stable Effect is rapid and predictable Indicated only if malocclusion is severe if not wait till permanent teeth erupts and carry on

43. EMDEN H A ( TAREK ZREIK ) 1994 It requires minimal cooperation. It allows more cases to be treated without extractions. It is easy to construct, fit, adjust, and clean. Materials are inexpensive, and breakage is minimal The lower splint increases anchorage and restricts forward movement of LI.

44. . 039 x .079 wire – bend into framework on lower model for acrylic splint Solder herbst plungers to framework between cuspids and pm1 Cold cure acrylic – base of acrylic splint Vacuum press a 2-3mm biocryl sheet over model

45. Reactivation - 2mm every six weeks. Average treatment time was six months, Mean overjet reduction was 5.2mm Mean molar correction was 6.5mm

46. Flip-Lock Herbst Appliance A new design, reduces the number of moving parts that can lead to breakage or failure. It is easy to use and more comfortable for the patient than the conventional Herbst. Instead of a screw attachment, it has a ball-joint connector, and it needs no retaining springs . FLIP LOCK ( ROBERT A MILLER ) 1996

47. The first generation was made from a dense polysulfone plastic but breakage occurred because of the forces generated within the ball-joint attachment

48. In the second generation , the plastic was replaced with metal

49. The third generation is made of a horse-shoe ball joint . This system has proved to be more efficient than the previous models, both in terms of application as well as its resistance to fracture

50. ADVANTAGES Improved pt compfort and acceptance Fewer clinical problems compared to screw or pin attachments Less chair time for activation Less frequent emergency appointments

51. End of rod is crimped onto mandibular ball. Advantages : Less irritation reduces the number of moving parts that can lead to breakage or failure

52. Mand Protraction App ( carlos martins coelho ) 1991,1998,2001

53. They are easily fabricated at chairside with ordinary, inexpensive wires. Do not require any special bands, crowns, or wire attachments. No impressions or wax bite registrations are used, and no laboratory assistance is needed. Easily inserted, adjusted, and removed. Can be made and installed in about 30 minutes. They are much smaller and thus more comfortable and acceptable to patients than other appliances. They permit a greater range of motion and are less restrictive of movement than other

54. MPA 1

55. MPA 1I

56. Two maxillary tubes of .045" internal diameter, each about 27mm long Two maxillary loops of .040" stainless steel wire, each about 13mm long, with a loop bent into one end at an angle of about 130° to the horizontal Two mandibular rods of .036" stainless steel wire, each about 27mm long Four pieces of band material Two short lengths of annealed .036" stainless steel wire, each with a loop in one end, for attaching the appliance to the maxillary molar headgear tube MPA III

57. MPA III

58. MPA IV “ “T” tube ; Upper molar locking pin ; Mandibular rod ; Mandibular archwire

59. The amount of activation will be determined by the number of turns in the coil

60. The Mandibular Protraction Appliance has proven to be effective during approximately 10 years of clinical use. This fourth version seems to be as efficient as its antecedents, but is much more practical to construct, easy to manipulate, and comfortable for the patient

61. The Intraoral Snoring-Therapy Appliance is a fresh device to treat patient suffering from inhalation problems during sleep, e.g. obstructive sleep apnea. According to the creator, the IST appliance overturns snoring by moving the mandible forward that reduce the obstruction in the pharyngeal area. T IST (INTRA ORAL SNORING THERAPY) APP ( Hinz germany )

62. The device offers two very important advantages: The telescope is attached so the operator can change the protrusion on each side separately up to 8mm. An end stop in the guiding sleeve prevents the telescope from disengaging. The appliance is available in two more lengths. .

63. Mandibular advancing repositioning splint. The MARS appliance is composed of a pair of telescopic struts, the ends of which are attached to the upper and lower archwires of a multi-banded fixed appliance by means of locking device. MARS APPLIANCE ( Ralph Clements and Alex Jacobson ) - 1982

64. Alignment must be complete . prior to attachment of the appliance. The MARS appliance should be attached only to the heaviest rectangular arch wires that can be accommodated by the brackets and tubes. The heavy arch wire prevents breakage at the point of attachment as well as excessive intrusion in the region of the mandibular canines. The mandibular arch wires should be securely tied back to the terminal molar before attachment of the MARS appliance.

65. Herbert appliance vs the MARS appliance : Requires neither soldering nor extensive lab procedures. Has minimal incidence of breakage Does not depress the canines, open spaces in the premolar area or flare mandibular incisors (provided the mandibular rectangular archwire is tied back to the terminal molars) Is easily removed.

66. The Ritto Appliance can be described as a miniaturized telescopic device with simplified intraoral application and activation It is a single piece device with telescopic action. It is used on both side due to its Jingle format. Total length of appliance when closed is 25mm and at maximum opening is 33mm. RITTO APPLAINCE ( RITTO A. K- 1998)

67. Fixation accessories consist of a steel ball pin and a lock. Upper fixation is carried out by placing a steel ball pin from the distal into the .045 headgear tube on the upper molar band, through the appliance eyelet and then bending it back on the mesial end.

68. The appliance is fixed onto a prepared lower arch and is activated by sliding the lock along the lower arch in the distal direction and then fixing it against the Ritto Appliance.

69. It consists of buccal attachments soldered to maxillary and mandibular molar crowns. The attachments contain a standard edgewise tube and a large 0.070 inch molar tube. Large rods pass through these tubes. The mandibular rod inserts from the mesial of the molar tube and is fixed at the distal by a screw clamp. By moving the rod mesially the appliance is activated. BIOPEDIC APPLIANCE ( Jay Collins in 1997 GAC Internationa )

70. This short maxillary rod is inserted screw at the mesial of the maxillary first molar. The two rods are connected by a rigid shaft and have pivotal region at their ends. Although, it appears that there would be limitation of mandibular opening, it is not so. The design works more in harmony with the arc of mandibular opening.

71. FLEXIBLE FIXED FUNCTIONAL APPLIANCES

72. DEFINITION an appliance that produces all or part of its effect by altering the position of the mandible Functional orthopedic treatment seeks to correct malocclusions and harmonize the shape of the dental arch and orofacial function. Developed primarily in Europe by many clinicians in an affort to stimulate mandibular growth , and aid in the correction of skeletal class-2 malocclusion s It is intended to alter mandibular growth . DEFINITION

73. Disadvantages of removable functional appliances Very bulky, Have unbalanced fixation, Absence of tactile sensibility, comfort, Apply pressure on the mucosa (causing gingivitis), Cause problems in deglutition, speech Reduce space for the tongue & commonly affect facial appearance.

74. Unfortunately due to the bulk and inconvenience , removable functional appliance fails to attract the patient’s cooperation. In addition, their intermittent wear does not elicit continuous muscle activity , a factor that is very essential for promoting skeletal change. Patient cooperation - an important factor, failure to adhere to prescribed schedules of removable appliance wear will result in slow treatment response or no response at all. To reduce these factors the Fixed functional appliances were developed

75. Rigid FFA Hybrid FFA Flexible FFA Herbst its modifications MARA MPA (I, II, III, IV) MARS IST Biopedic appliance Ritto app Magnetic Telescopeic Device UBJ Jasper jumper Amoric torsion coils Adustable bite corrector Klapper super spring Churro jumper Scandee tubular jumper Eureka spring Forsus Twin force bite corrector Calibrated force module Alpern class II closer Classification by Ritto korrodi (2001)

76. This interarch flexible force module allows patient greater freedom of mandibular movement than is possible with the original bite jumping mechanism of Herbst. JASPER JUMPER ( Dr. James Jasper ) 1987 JAMES JASPER; MC. NAMARA., Corrections of interarch malocclusions using a fixed force, module, AJODO 1995

77. 2 parts – force module; anchor units Force Module : The force module, analogous to the tube and plunger of the Herbst bite – jumping mechanism and is flexible . Constructed of stainless steel coil of spring attached at both ends to stainless steel end caps in which holes have been drilled in the flanges to accommodate the anchoring unit. This module is surrounded by an opaque poly urethane covering for hygiene and comfort. JAMES JASPER; MC. NAMARA., Corrections of interarch malocclusions using a fixed force, module, AJODO 1995

78. The modules are available in seven lengths ranging from 26 to 38 mm in 2 mm increments. They are designed for use on either side of the dental arch. JAMES JASPER; MC. NAMARA., Corrections of interarch malocclusions using a fixed force, module, AJODO 1995

79. When the force module is straight, it remains passive. As the teeth come into occlusion, the spring of the force module is curved axially as the muscles of mastication elevate the mandible, producing a range of forces from 1 to 16 ounces JAMES JASPER; MC. NAMARA., Corrections of interarch malocclusions using a fixed force, module, AJODO 1995

80. 1. Attachment to the main arch wire When the jumper mechanism is used to correct a class II malocclusion, the force module is attached Posteriorly to the maxillary arch by a ball pin placed through the distal attachment of the force module. The module is anchored anteriorly to the lower arch wire (0.018”x 0.025” or 0.0x0.025” ). JAMES JASPER; MC. NAMARA., Corrections of interarch malocclusions using a fixed force, module, AJODO 1995 ANCHORING UNIT :

81. Bayonet bends are placed distal to the mandibular canines and a small Lexan ball is slipped over the archwire to provide an anterior stop. The mandibular archwire is threaded through the hole in the anterior end cap and then ligated in place. The first and second bicuspid brackets are removed to allow the patient greater freedom of movement. JAMES JASPER; MC. NAMARA., Corrections of interarch malocclusions using a fixed force, module, AJODO 1995

82. 2. Attachment to auxiliary arch wires : JAMES JASPER; MC. NAMARA., Corrections of interarch malocclusions using a fixed force, module, AJODO 1995

83. Effcts : 40% - skeletal; 60% - dental acc. t o Rankin, and Parker

84. Skeletal changes The increase in mandibular length - due to condylar growth stimulation as an adaptive reaction to the forward positioning of the mandible -> clockwise rotation of mandible. The gonion angle increased slightly. (This may be due to a more sagittally directed growth of the condyle or it may result from resorptive bone changes in the gonion region, probably as a consequence of an altered muscle function during bite jumping). Stimulating effect on mandibular growth + restraining effect on maxillary growth

85. Dental changes Posterior tipping and intrusion of upper molars; Backward tipping of maxillary incisors; Anterior translation and tipping of mandibular teeth; Intrusion of mandibular incisors

86. Jasper’s theory of two’s” Suggests that class II correction with Jasper jumper therapy can be equally proportioned between 5 components. 20% due to maxillary basal restraint 20% due to backward maxillary dento alveolar movement 20% due to forward mandibular dentoalveolar movement 20% due to condylar growth stimulation 20% due to downward / forward glenoid fossa remodeling JAMES JASPER; MC. NAMARA., Corrections of interarch malocclusions using a fixed force, module, AJODO 1995

87. It is flexible . The jaws can open fully . Force is directed distal to the molar; if the archwire breaks there is no effect on the anterior teeth. The jumper does not interfere with space closure or leveling procedures . No auxiliary tubes are needed on the mandibular molars. Advantges JAMES JASPER; MC. NAMARA., Corrections of interarch malocclusions using a fixed force, module, AJODO 1995

88. Unattached bicuspids tend to erupt above the occlusal plane as the anterior teeth are intruded. When only the lower 1st bicuspid bracket used to be removed as originally suggested by Dr. Jasper, Jaw opening used to be limited as the lower portion of the jumper tends to bind at the 2nd bicuspid. Disadvantages JAMES JASPER; MC. NAMARA., Corrections of interarch malocclusions using a fixed force, module, AJODO 1995

89. Replacement of a broken jumper required removal of the entire archwire . Removing the Jumper is time consuming If an arch breaks or comes untied at the distal tieback, all the force is transferred to the anterior teeth, which tends to tip them forward depress them and open space . JAMES JASPER; MC. NAMARA., Corrections of interarch malocclusions using a fixed force, module, AJODO 1995

90. Bilateral appliance 2 intermaxillary springs One inside the other Have rings on the ends through which it is attached using double ligatures Amount of force exerted is prop. To fixing points on the arch Marketed in one size only AMORIC TORSION COILS ( Amoric . N ) 1994 AMORIC M. Les Ressorts intermaxillaries en torsion. Rv. Orthop . Dento Facial 1994; 28: 115-117

91. The appliance essentially consists of: A stretchable closed coil spring and internally threaded end cap nickel titanium wire in the centre lumen of the spring. The closed coil spring is made of 0.018 ” stainless steel, and will stretch to about 25% beyond its original length without permanent deformation. ADJUSTABLE BITE CORRECTOR ( Richard P. West ) 1995 Journal of Cinical Orthodontics 1995; 29, 650-657

92. The ABC can be used on either side of the mouth with a simple 180  rotation of the lower end cap to change it orientation. Functions similar to the Herbst and Jasper Jumper but also incorporates several useful features like a) Universal right and left b) Adjustable length and force Journal of Cinical Orthodontics 1995; 29, 650-657

93. After the patient has postured forward into an improved profile with ideal overbite / overjet the point of the gauge is placed into the mesial opening of the headgear tube. The size is then read at point about 3mm below the contact between lower cuspid and first premolar using the correct appliance size ensuring optimum force delivery. Journal of Cinical Orthodontics 1995; 29, 650-657

94. The ABC can be lengthened as much as 4mm, or two and a half turns at each end. Going beyond this will cause the spring to pull out of the end cap when the patient opens wide and pulls on the spring . These adjustable feature can be used for treatment of asymmetrical problems or midline shifts Journal of Cinical Orthodontics 1995; 29, 650-657

95. It resembles a Jasper Jumper with a substitution of a cable for the coil spring. In 1998 the cable was wrapped with a coil and the Klapper superspring II was the result. Only two sizes are required (left and right sides are not interchangeable) and breakage is less frequent. However it differs significantly from the Jasper Jumper at the molar attachment. The Klapper Superspring II ( Lewis Klapper in 1997 ) THE super spring ii a new appliance for non – compliant class II patients, JCO 1999;33:50-54

96. The SUPERspring II is a flexible spring element that attaches between the maxillary molar and the mandibular canine. It is designed to rest in the vestibule, making it impervious to occlusal damage and allowing for good hygiene. Only minor adjustments are needed for patient comfort, without any impingement on soft tissues. THE super spring ii a new appliance for non – compliant class II patients, JCO 1999;33:50-54

97. Useful in variety of class II cases from hyperdivergent to brachyfacial patterns with shallow and deep overbites Commonly used with fixed mechanotherapy The SUPERspring II has eliminated nearly all Class II compliance problems – without premature debonding , and with cases finished to a satisfactory standard THE super spring ii a new appliance for non – compliant class II patients, JCO 1999;33:50-54

98. CHURRO JUMPER ( RICARDO CASTAÑON, MARIO S. VALDES, LARRY W. WHITE ) - 1998

99. It is made of a series of 15-20 symmetrical and closely placed circles are formed in a wire. The wire size can be .028" to . 032“

100. The length of the jumper is determined by the distance from the distal of the mandibular canine bracket to the mesial of the headgear tube on the maxillary molar band, plus 10-12mm . This measurement is transferred to the Churro Jumper, with the coil closer to the canine bracket than to the headgear tube.

101. A circle is then formed at each termination mark on the Churro wire, so that the coils of the jumper lie against the cheek and the terminal circles face the teeth. The maxillary circle is completely closed, but the mandibular circle is only partially closed to allow its placement over the mandibular archwire and subsequent closure.

102. A pin made of . 036" wire is used to secure the maxillary circle through the distal of the headgear tube. The maxillary pin is pulled mesially through the headgear tube until the jumper has a slight buccal bow in it, and is then turned down (Fig. 9). Initially, the pin is not cinched tightly against the tube, which improves patient comfort and allows space for later adjustments. At subsequent appointments, as the teeth move and adjust to the forces of the Churro Jumper, the headgear pin is pulled forward to reactivate it.

103. The mesial end of the Churro Jumper is an open circle that is placed over the mandibular archwire , against the canine bracket . In its passive form, the Churro Jumper is not flexed. However, when the pin is pulled forward enough to cause the jumper to bow outward toward the cheek, the appliance exerts a distal and intrusive force against the maxillary molar and a forward and intrusive force against the mandibular incisors as it attempts to straighten

104. This jumper can be used unilaterally in cases of class II subdivision malocclusions. The bilateral class II churro jumper is most suitable for patients who need mandibular incisors advancement. By reversing the attachments, the churro jumper can also be used to treat class III malocclusions . It is universal in size and can be adapted to fit any malocclusion. When broken, it is easily and inexpensively removed and replaced.

105. disadvantages Not a very good choice for class II bimaxillary proclination cases. The restriction of mouth opening to 30-40mm is intolerable for some patients. Archwire breakage is common if larger wires are not used.

106. Scandee tubular jumper ( S candee , norway ) - 1999 Highly coated intermaxillary torsion spring Kit consists of spring, connectors, ball pins, coverings Right and left sides cannot e differentiated Different colors of coverings available When fracture occurs it is only necessary to replace individual components Drawback: it is thick after covering is palced

107. HYBRID FIXED FUNCTIONAL APPLIANCES

108. Rigid fixed appliances – restrict mandibular movement Flexible fixed appliances – greater chance of breakage To overcome these drawbacks hybrid fixed functional appliances

109. EUREKA SPRING ( Dr. DeVincenzo ) 1997 Fore runner to EUREKA SPRING was a system deviced by Northcutt in 1974 Northcutt device (1974) A pair of spring arrangements are provided to assist the patient in moving his upper row of teeth rearward), and his [lower row of teeth forwardly each time he closes his mouth, utilizing the vertical closure force of his masseter muscle converted into horizontal corrective vectors The vertical closure force of the masseter muscle is about 25,000 pounds per square inch, and the present invention converts this huge force into horizontal corrective vectors

110. Changes to Northcutt’s design, Including triple telescoping action, Flexible ball-and-socket attachments, Completely encased spring that remains intact even if the device becomes disengaged, Shaft for guiding the spring The main component of the Eureka Spring is an open-wound coil spring encased in a plunger assembly EUREKA SPRING ( Dr. DeVincenzo ) 1997

111. most important characteristics of an ideal system are as follows (in decreasing order of importance) Ability to function without the need for patient cooperation . Cooperation is essential with Class II elastics, and some cooperation is required with Saif and Sentalloy springs, since the patient must remember to avoid breakage by not opening the mouth too wide. Minimal cooperation is required with the Eureka Spring, Jasper Jumper, and fixed Herbst . Esthetic acceptability to patients . Eureka Spring , is almost invisible because of its small size and lack of protuberances into the buccal vestibule.

112. Resistance to breakage. Other appliances break far too often; breakage of elastics discourages patient cooperation and probably prolongs treatment time. Forces in the range of 220-280g can be measured at the points of attachment in closure of the Jasper Jumper The Eureka Spring produces forces of only 140-170g at the points of attachment, reducing the possibility of breakage .

113. It never functions in any mode other than straight compression , which is evenly distributed over the entire length of the spring. Wave motion normally would develop within the spring as compression increases, but is prevented by the guiding shaft on the inside and the cylinder on the outside. These factors, along with the use of low-fatigue material, have produced a spring life of three to six months

114. Eureka Spring continues to work even when the mouth is opened as much as 20mm, as when sleeping, or when the mandible is thrust forward as far as 10mm in an attempt to minimize the force. The Jasper Jumper applies no force in these two positions. In addition, frequent breakage of the Jasper Jumper result in a wide range of correction rates.

115. Designed to substitute the elastics Telescopic device with an inner coil spring and hooks for fixing. Fixed to mandibular molar and to maxillary cuspid Alpern class II corrector ( GAC International Inc )

116. This is an interarch push spring which produces about 200g of force when fully compressed. The distal end of the FRD`s push rod inserts into the telescopic cylinder and a hook on the mesial end is crimped directly to the archwire near the canine or premolar brackets. Forsus : Fatigue resistant Device ( William vogt – 2006 3M UNITEK )

117. The push rod has a built in stop that compresses the spring when the patients mouth closes. The spring is then transferred to the maxillary molars using the mandibular arch as the anchorage unit. The L-pin is inserted in the eyelet of the telescoping spring and is threaded through the molar headgear tube from distal to mesial and cinhed , leaving 2mm slack. The mesial hook is looped over the mandibular arch wire and crimped shut.

118. The appliance’s flat surface is more esthetically acceptable and it offers more comfort. The Forsus Nitinol Flat Spring is slim, flat and made of Super-Elastic Nitinol. Force levels remain constant from the initial setup to the time of removal. The result is faster, more efficient treatment.

119. ` Heinig N, Goz G 2001 reported the use of Forsus spring over a period of 4 months to treat 13 patients with an average age of 14.2 years with Class II malocclusion. RESULTS : lateral cephalograms showed that dental effects accounted for 66% of the sagittal correction. The sagittal occlusal relations were improved by approximately 3/4 of a cusp width to the mesial on both the right and left side as a result of distal movement of the upper molars and mesial movement of the lower molars. Retrusion of the upper and protrusion of the lower incisors reduced the overjet by 4.6 mm . Intrusion and protrusion of the lower incisors reduced the overbite by 1.2 mm .

120. The occlusal plane was rotated by 4.2 degrees in clockwise direction as a result of intruding the lower incisors and the upper molars. The maxillary and mandibular arches were expanded at the front and rear during treatment. The main problem , however, was the restriction experienced in the ability to yawn . Overall, two thirds of the adolescents found the Forsus spring better than the appliance previously used to correct their Class II malocclusion, such as headgear, activator or Class II elastics. CONCLUSION: The Forsus spring has stood the test in clinical application. It is a good supplement to the Class II appliance systems already available.

121. This appliance differs from others in form and constitution because it has two internal coil springs. It consists of two joint telescopic systems. At the superior level it is fixed with a ball pin that is fitted into the buccal tube of a molar band. The placement in the lower arch is slightly different; it involves a fitting-in system that is later fixed with a screw to the inferior arch. Normally it is placed distal to the lower cuspid . TWIN FORCE BITE CORRECTOR

122. Powerscope provides best non extraction option for class II situations due to functional retrusion of mandible in non compliant pts Indicated for both growing and non growing patients Pts with average axial inclination of upper and lower incisors Contraindicated in pts with nickel allergy , compromised periodontal condition or absence of complete permanent dentition Power Scope ( Dr. Andy Hayes )

123. parts Locking nut attachment Telescopic system Niti spring Head screws Crimpable shims Hex head driver Driver magnets

124. Contra Indications Nickel allergy Vertical growth pattern Compromised dentition Periodontal problems Indications Class II correction with dentoalveolar compensation Class II div 1 and 2 cases Unilateral class II correctins Asymmetric midline corrections

125. Conclusion : Fixed functional appliances form an useful addition to the clinician’s orthodontic armamentarium. But many of these appliances need further studies to substantiate the claims made by their respective originators. With this in mind, clinicians must take great care in selecting the right patient and also pay attention to every detail in the manipulation, to attain successful results with these appliances.

126. Title Lorem Ipsum Dolor

127. Title Lorem Ipsum Dolor

128. Carriere appliance ( carrier )

129. Its low profile results in considerably less buccal irritation than with similar appliances. Patient comfort and acceptance are excellent. It can easily be attached to removable splints for maximum anchorage. It produces good results without the need for patient cooperation.